Thyroidectomy Basics

Synonyms: Thyroid resection surgery, Thyroid removal surge

Definition: Thyroidectomy is the surgical removal of all or part of the thyroid gland. A “thyroidectomy” should not be confused with a “thyroidotomy” (“thyrotomy”), which is a cutting into the thyroid, to get access for a median laryngotomy, or to perform a biopsy.

Indications:

1. Proven neoplasm (FNAC)
2. Suspected neoplasm
   • Age: Extreme
   • Sex: Male
   • Hard, irregular texture and fixity
   • Hoarseness of voice
   • Enlarged cervical nodes
3. Recurrent cysts
4. Pressure symptoms due to goiter
5. Patient’s wish or Cosmesis

Types of thyroidectomy:

Thyroidectomy types	Resected parts	Indications
Lobectomy or Hemithyroidectomy	Isthmus (Isthmectomy) + 1 lobe of thyroid	Benign diseases of single lobe: a. Recurrent cysts b. Solitary toxic  or non-toxic adenoma Minimal Papillary carcinoma (<1 cm, no local invasiveness, no lymph node metastases)
Subtotal thyroidectomy	All except about 4 grams of lobe on each side	Toxic multinodular goiter (MNG) Hashimoto’s disease
Near-total thyroidectomy	All except a rim of thyroid tissue (<1 gm or 1 cm) on one or both sides – saves parathyroid and recurrent laryngeal nerve	Suspicious for malignancies Malignancies
Total thyroidectomy	All	Malignancies (Papillary carcinoma, Follicular carcinoma, Meduallry carcinoma)
Completion thyroidectomy	Remnant thyroid tissue following procedures less than total or near-total thyroidectomy.	Malignancy detected on biopsy
Hartley-Dunhill operation	Lobectomy on one side + Subtotal thyroidectomy on other side	Non-toxic Multinodular Goiter (MNG)

Note: Anaplastic carcinoma of thyroid gland is often inoperable. Isthmectomy may be done to relieve the tracheal compression.

Modalities of thyroidectomy:

1. Conventional thyroidectomy
2. Endoscopic thyroidectomy
3. Robotic thyroid surgery

Steps of thyroidectomy:

1. Anesthesia: General anesthesia with Endotracheal intubation

2. Position: Supine with neck hyper-extended by placing a sand-bag under shoulder; table titled to 30° anti-trendelenburg position to reduce venous engorgement

3. Kocher’s thyroid incision: Transverse “collar” incision, 2 finger breadths above the suprasternal notch from one sternocleidomastoid to another

4. Development of subplatysmal plane:

• Skin flaps retracted together with platysma – upper  flap raised upto thyroid cartilage and lower flap upto sternoclavicular joint.
• Investing layer of deep cervical fascia is opened longitudinally between strap muscles and between anterior jugular veins.

5. Retraction of strap muscles: Away from thyroid

6. Exposure of thyroid gland: through vertical division of pretracheal fascia

7. Ligation of middle thyroid vein: 1st vein to be ligated

8. Mobilization of thyroid and ligation of vessels in series: Superior followed by inferior

Note: Parathyroids must be identified and Recurrent laryngeal nerve should be identified and saved in Beahr’s or Riddle’s triangle formed by Common carotid artery, Inferior thyroid artery and tracheo-esophageal groove.

9. Division of Berry’s ligament: Separation of isthmus and thyroid lobe from trachea

10. Removal of thyroid: Based on the type of thyroidectomy – the procedure may be repeated on the other side as well

11. Wound closure:

• Reapproximate strap muscles and platysma
• Skin closure with subcuticular stitch
• Dressing

Complications of thyroidectomy:

Intra-operative:

1. Anesthetic complications
2. Bleeding
3. Thyrotoxic storm (in cases of toxic glands)
4. Recurrent Laryngeal Nerve (RLN) injury
5. Injury to other surrounding structures

Early:

1. Respiratory obstruction:
   • Hematoma
   • Laryngeal edema
   • Recurrent laryngeal nerve injury
2. Thyroid strom
3. Hypocalcemia
4. Wound infection

Late:

1. Hypothyroidism
2. Hypoparathyroidism
3. Keloids
4. Stitch granuloma